The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology www.ifhnos.net
The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology Jatin P. Shah
Thousands 60 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 Thyroid Cancer Incidence & Mortality 1974 to USA Overall 62450 Women 47230 Men 15220 Mortality 1950 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 Overall Incidence Incidence in Men Incidence in Women Mortality
Misconceptions about Thyroid Cancer All patients need subtotal or near total Thyroidectomy All patients need Post Operative Radio Active Iodine ablation Post operative TSH should be brought down to 0 Follow up requires annual whole body radio active scans
Pathology - Biology Cancer of the Thyroid Papillary Thyroid Follicular Cell Tall Cell, Insular, etc Poorly differentiated Anaplastic Follicular Prognosis Good Bad Ugly ~85% ~14% <1%
Prognosis in Thyroid Cancer A very small proportion ~ 10 % of Papillary carcinomas will undergo progression to more aggressive variants Prognosis worsens PTC Tall Cell Poorly Diff Anaplastic Size, ETE, DM, Mortalit
Well Differentiated Nearly All Curable Thyroid Cancer Poorly Differentiated Need Aggressive Rx Majority Curable Anaplastic Rarely Curable
Differentiated Thyroid Cancer Prognostic Factors Mayo Lahey Mayo Karolinska MSKCC AGES AMES MACIS DAMES GAMES Age Grade Age Metastases Metastases Age Completeness Of resection DNA Age Metastases Grade Age Metastases Extension Extension Invasion Extension Extension Size Size Size Size Size
Importance of Prognostic factors Allows Risk Group Stratification Permits selective surgical treatment Permits selective use of Radio active Iodine Permits appropriate follow up strategies Delivers cost effective evidence based treatment Allays anxiety on the part of the patient Delivers excellent outcomes
Differentiated Cancer of the Thyroid Survival - Age <45y n=845 >=45y n=915 P<0.001
Differentiated Cancer of the Thyroid Age Group (y) Disease Specific Survival by Age <30 30-39 40-49 50-59 60-69 70+ 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 10y DSS
Differentiated Cancer of the Thyroid Survival Size T Stage (T1,T2 vs T3,T4) < 4cm n=1584 >=4 cm n=207 P<0.001
Differentiated Cancer of the Thyroid Survival Extra Thyroid Extension None n=1290 Microscopic n=317 Macroscopic n=203 P<0.001
Differentiated Cancer of the Thyroid Survival p N Stage pn0 n=1206 pn1 n=604 P<0.001 5 year outcomes shown
Differentiated Cancer of the Thyroid Age Distribution of N+ Patients
Differentiated Thyroid Cancer Survival N Status Age < 45 Age > 45
Disease Specific Survival Age 45 years cut off Age 55 years cut off Stag e 10y DSS I 100% II 97% III 97% IV 80% Stag e 10y DSS I 100% II 94% III 94% IV 72%
Differentiated Cancer of the Thyroid Survival M Stage M0 n=1757 M1 (Mx) n=53 P<0.001 5 year outcomes shown
Differentiated Cancer of the Thyroid Prognostic Factors Risk Groups (GAMES) Low Intermediate High Age <45 >45 <45 >45 Gender Size Extent Grade Dist. Mets. Female < 4 cms. Intraglandular Low Absent Male > 4 cms. Extraglandular High Present
Risk Group Stratification Based on Prognostic Factors Risk Group Stratification is the most important clinical parameter for selection of the extent of initial surgery, the need for adjuvant therapy, the degree of rigorous follow up, and for the assessment of over all prognosis, for local, regional, or distant failure and Survival.
Differentiated Cancer of the Thyroid Disease specific Survival Risk Groups (GAMES) Low n=576 Intermediate n=817 High n=417 P<0.001 5 year outcomes shown
Extent of Thyroidectomy for Cancer All thyroid operations done for proven or suspected Cancer should be Extra capsular Subtotal Thyroidectomy and Near Total Thyroidectomy transgress thyroid tissue, and therefore are not Cancer operations, and should not be done There are only two Oncologic operations: Lobectomy or Total Thyroidectomy
Extent of Thyroidectomy for Cancer Extra capsular operations leave no residual thyroid tissue behind, and thus avoid the need for RAI ablation Pay special attention to the upper pole, pyramidal lobe and the region of the cricothyroid membrane Following an extracapsular total thyroidectomy, TGb is not measurable at 6 weeks, and thus it allows bio chemical follow up
Lobectomy
Total Thyroidectomy
Extra Thyroid Extension Most important factor impacting on the extent of Surgery
Differentiated Cancer of the Thyroid Extra Thyroid Extension Microscopic: Not Staged ( No impact) Minor: T3 Major: T4A Strap muscles Soft tissues Trachea Larynx Esophagus Recurrent laryngeal nerve
Extra Thyroid Extension T4a Disease specific Survival by completeness of Resection ( R Stage ) R0 96% R2 63% R1 60% R0 Gross Clearance R1 Micro. Residual R2 Gross Residual P<0.001 Time (Months)
Extrathyroid Extension Principles of Surgery All gross tumor should be removed Preserve functioning structures Preserve vital structures Balance between tumor control and best functional results Use adjuvant treatments - RAI, and/or RT
Cervical Lymph Nodes Micro metastases are common >50% Occult metastases have no impact on prognosis in low risk patients Elective node dissection is not recommended in low risk patients Therapeutic neck dissection is indicated for metastatic nodes identified clinically, on imaging studies or intra operatively Berry picking is not recommended Lymph node dissection should be compartmental and comprehensive
Patterns of Neck Metastases For differentiated cancer of the Thyroid gland AJCC/UICC 2009 Staging Nodal Staging for Thyroid Cancer N x regional lymph nodes cannot be assessed N 0 No regional lymph node metastases N 1 Regional lymph node metastases Central Compartment Node Dissection Level VI & VII N 1a Metastases to Level VI pretracheal, paratracheal, prelaryngeal, delphian N 1b Metastases to unilateral, bilateral or contralateral cervical or superior mediastinal lymph nodes Modified Neck Dissection Type III Lymph node dissection Level I not usually Level II - V Structures preserved Submandibular gland Internal jugular vein Sternocleidomastoid Spinal Accessory
Central Compartment Node Dissection
Lateral Neck Dissection
Distant Metastases Radio active Iodine External Radiotherapy ( selected cases) Surgery (Palliative) Chemotherapy?? Targeted Therapy (Investigational) Agents under study: Sorafinib, Lenvatinib, Selumetinib, Pazopanib, Vandetinib, Cabozantinib, other
Differentiated Cancer of the Thyroid Mortality 1810 patients ( 1985-2005) Excluded M1 and unresectable N=1752 Median f/u = 100 months 165 deaths 17 died of disease 6 died from unknown causes with disease Disease specific mortality 1.3%
Differentiated Cancer of the Thyroid Trends in Mortality Author Year Death Rate Central Neck Disease *Tollefsen 1964 10% >40%* Smith 1988 7% 36% Shaha 1996 9% 10% Kobayashi 1996 5% <28% Ronga 2002 4% 12% **Nixon 2012 1% 0% ** * Locoregional recurrence was a common cause of death ** Locoregional recurrence is a rare cause of death
Thank You